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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 7 5 8
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10610
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
/IX m" SOA/
YES ❑ If yeal understand that a Class A
NAME • IWVN
roof assembly is required.
N Initial I.C.B.O. #
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EXISTING ROOF COVERING
'ADDRESS
• PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
/
L x l
NAME IAI/9
TO BE REMOVED TO BE RETAINED
ADDRESS
P p y
M-5. 5y>10 i>
&E OF ROOF COVERING
CITU 8 ZIP— i -�•8 _3�3
EXISTING
7-7'7 g33/
PHONE -
BUILT-UP ROOF ❑
LICENSE
NUMBER Z
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencin Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is I e and
effect. n
License Class �— `� Lic. Number zg
WOOD SHINGLES ❑
!/ Jr.
OTHER (SPECIFY) ❑
Data Contleptpf
OWNER-BUILDE LARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
construct, alter,Improve,demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter B (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($500).):
d,1, as owner of the or my employees do
WOOD SHAKES ❑
property, with wages as their sole compensation, will
the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes.
owner of property who builds or
Improves thereon, and who does such work lo hrois own employees, Provided that
sions Code: The Contractors License Law does not apply�he
such improvements are not Intended or offers e. ll,ver, the building or improvement
WOOD SHINGLES ❑
Q,i i
Is sold within one year of completion, theowl er wllth urs of provingthat he did
Ely
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
Ql, as owner of the property, am excfualytracing wit sad contractors to construct
x Zx yNi-mi'v•
the project (Sec. 7044, Business and Professions Code: The con, License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
Q I em exempt under Sec. ,S 8 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLI TION DATEI
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
p
Q 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permh
Y
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Building
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veuetl.
have entl will maintain Worker's Compensation Insurance, as required by Section 3700 01(//
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Seismic
e Labor Cotle, for the performance of the work for which this permit Is Issued, My Worker's
Compensation Insurance carrier and Policy number are:
(✓r •K�TI�!
L/
Total
fru
T otip I I y'd� 9-cfIs,
PERIKIMAUTHORIZATION
DATE
Carder/ Policy No. Ak
CERTIFICATE OF EXEMPTION FROM WORKERS'
_
COMPENSATION INSURANCE N.C.Q
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
I certify that In the performance of the work for which this permit is Issued, I shall not employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to became subject to the Workers' Compensation Laws of call-
fornia.
IA—
installed. If a roof is installed without first obtaining an
Date Applicant ,V
inspectio Be o ove all new materials for inspection.
NOTICE TO APPLICANT: If, alter making is Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith comply
A 'ant understa sand will comply
P p y with all non point
with such provisions or this permit shell be deemed revoked,
urCe regulatio
I certify that I have read this application and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof cove ' g p to a cl BS "C" or better.
herebhereby authorize representatives o/ this city to enter upon the above-mentioned properly kr in.
y n purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino a alnst liabilities,
judgments, costs and expenses which may In any way accrue against said City In consequence
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of the granting of this permit.
GNATURE OF APPL A T DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY